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Communication Breakdown

Nurse Grad Issue 2007 • Page 65
Communication Breakdown

The Joint Commission offers solutions to help providers and patients worktogether to eliminate low health literacy

Communication breakdowns — whether between care providers and their patients or each other – are the primary root cause of the more than 3,000 unexpected deaths or catastrophic injuries that have been reported to the Joint Commission.1 People with low health literacy are hospitalized more often and for longer periods of time, use EDs more frequently, and manage their diseases, asthma and diabetes in particular, less proficiently.2

That's not surprising, but new grads (and veteran nurses) should be aware of the sheer number of people who struggle with literacy. A large segment of the American population has basic (29 percent) to below basic (14 percent) literacy skills. An additional 5 percent are nonliterate in English. About half of the U.S. adult population has difficulty using text to accomplish everyday tasks.

The ability of the average American to use numbers is even lower — 33 percent have basic and 22 percent have below basic quantitative skills. These skills include the ability to solve one-step arithmetic problems (basic) and simple addition (below basic).3

All of these groups must obtain, process and understand complex insurance and consent forms, as well as medication instructions. Even proficient patients can be compromised when they are challenged by sickness and feelings of vulnerability, according to the Joint Commission.

Far too often, ordinary citizens are placed at risk for unsafe care because important healthcare information is communicated using medical jargon and unclear language that exceeds their literacy skills, according to a call to action released by the Joint Commission in February 2007.

Nurses Play a Role

The Joint Commission recently released its newest public policy white paper, "What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety." This report is part of a continuing series of white papers on key public policy issues that impact patient safety and health care quality. The solutions were developed by a Joint Commission expert roundtable focused on making effective communications a priority in protecting the safety of patients, addressing patient communication needs across the spectrum of care, and pursuing public policy changes that promote better communications between healthcare practitioners and patients.

"Breakdowns in communication between patients and caregivers can significantly impair the ability of physicians to diagnose and treat medical problems," said Ronald M. Davis, MD, chair of The Joint Commission Expert Roundtable of Health Literacy and director of the Center for Health Promotion and Disease Prevention at Henry Ford Health System, Detroit. "Everyone who has a role in healthcare – specifically including practitioners, employers and regulators — must work together to pursue strategies for improving communications with patients that will result in safer, more effective care."

Terri Tye, director of public affairs for The Joint Commission, agrees. "Nurses have a critical role in patient communication. They are often the patients' [main] source of communication," she told ADVANCE, adding that it's important for nurses to utilize tools such as "teach back" or "show back" when showing a patient how to give a themselves a shot, for example.

"A lot of organizations are working on this issue, but since the release of this report, it's struck me how much physicians and nurses aren't familiar with health literacy," Tye continued. "They usually have an 'Aha!' moment and realize there are things they can do to help."

Recommendations & Solutions

The Joint Commission's public policy white paper offers three recommendations and 35 specific solutions to help all healthcare organizations improve communication.

First, the roundtable recommends making effective communications an organization priority to protect the safety of patients. Specifically:

  • raising awareness throughout the organizations of the impact of health literacy and English proficiency on patient safety;

  • training all staff to recognize and respond appropriately to patients with literacy and language needs;

  • creating patient-centered environments that stress the use of clear communications in all interactions with patients;

  • modifying strategies for compliance with the Joint Commission's National Patient Safety Goals to accommodate patients with special literacy and language needs;

  • using well-trained medical interpreters for patients with low English proficiency;

  • providing reimbursement to cover healthcare organization costs for providing trained interpreters;

  • creating organization cultures of safety and quality that value patient-centered communications as an integral component of delivering patient-centered care;

  • assessing the organization's patient safety culture by using a valid and reliable assessment tool, such as the Association for Healthcare Research and Quality Hospital Survey on Patient Safety Culture;

  • assessing the organization's stewardship and acculturation of patient-centered communications, such as through the AMA's Patient-Centered Communication Framework;

  • becoming knowledgeable about the literacy levels and language needs represented by the community served;

  • making cultural competence a priority as demonstrated by hiring practices that value diversity and the continuing education of the staff;

  • pursuing a research agenda to expand understanding of the impact that communication issues have on patient safety, disparities in healthcare and access to care.

    The Joint Commission's second recommendation is addressing patients' communication needs across the continuum of care. For example:

  • eliminating barriers to entry in the care system by educating patients, particularly those with low health literacy, about when to seek care;

  • developing and providing insurance enrollment forms, benefit explanations and other insurance-related information that are client centered;

  • ensuring easy access to healthcare organization services by using clear communications in all materials and signage

  • designing audience-centered public health interventions and communications;

  • applying communications techniques known to enhance understanding among patients, such as using plain language, using "teach back" and "show back" techniques, limiting information provided to two or three important points at a time, using drawings, models or devises to demonstrate points, and encouraging patients to ask questions;

  • employing a universal precautions approach to all patient encounters by using clear communications and plain language, and probing for understanding;

  • emphasizing learning of patient-centered communication skills in all health professional education and training;

  • adopting disease management practices, such as individualized education and multidisciplinary team outreach to patients;

  • redesigning the informed consent process to include forms written in simple sentences and in the language of the patient;

  • partnering with patients in shared decision-making and providing appropriate education;

  • engaging patients in their role as safety advocates by communicating with them about safety and giving them tools to permit their active involvement in safe practices;

  • standardizing the approach to hand-off communications, such as using clear language so key information isn't misinterpreted, using "teach back" and "check back" methods, standardizing shift-to-shift and unit-to-unit reporting, smoothing transitions to new care settings and giving patients information about all of their medications, diagnoses, test results and plans for follow-up care;

  • reconciling patient medications at each step along the continuum of care and providing each patient with a "wallet" card that lists all current medications and dosages;

  • addressing the special needs of the chronically ill so they are better prepared to self-manage their conditions;

  • providing self-management education to a patient that is customized to the learning and language needs of the patient;

  • regularly placing outreach calls to patients to ensure the understanding of the self-management regimen;

  • expanding patient safety taxonomies to begin to account for and understand patient safety risks associated with self-management.

    The Joint Commission's final recommendation is pursuing policy changes that promote improved provider-patient communications. The solutions include:

  • referring patients with low literacy to adult learning centers and assisting them with enrollment procedures;

  • encouraging partnerships among adult educators, adult learners and health professionals to develop health-related curricula in adult learning programs;

  • broadening reimbursement policies for patient education provided in physician offices;

  • pursuing pay-for-performance strategies that provide incentives to foster patient-centered communications and culturally competent care;

  • expanding the number of medical malpractice insurance companies that provide premium discounts to physicians who receive education on patient-centered communications techniques

  • expanding the development of patient-centered educational materials and programs to support the development of informed healthcare consumers.

    To view a complete copy of the Joint Commission's report, visit

    For a list of references, visit; click on References.

    Emily Marchesani is a freelance writer for ADVANCE.

    Study Shows Pediatricians Not Using Professional Interpreters

    Nearly two-thirds of pediatricians use untrained interpreters to communicate with families who are not proficient in English, according to a nationwide survey of doctors led by researchers at The Johns Hopkins University. Pediatricians in rural areas or in states with large numbers of Spanish-speaking patients were the least likely to use professional translation services. In addition, doctors in states where translation services were covered by public health insurance were more likely to use professional interpreters.

    The study was based on the results of a survey of 1,829 physicians from the American Academy of Pediatrics. Of the physicians surveyed, 70 percent reported using the patient's bilingual family member to relay health information and 58 percent reported using bilingual staff for assistance. Only 40 percent reported using professional interpreters, and 35 percent offered translated written materials in the office.

    "This is really an overlooked problem, given all that we know about the adverse health outcomes that can arise from miscommunication between physicians and their patients," said Dennis Z. Kuo, MD, MHS, a general pediatrics fellow at The Johns Hopkins School of Medicine and lead author of the study.

    The study was published in the April 2007 issue of Pediatrics.


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